Pre-Travel Assessment Form - Countries

*First Name: *Last Name: *Birth Date: (dd/mm/yyyy)
*Occupation: *Email Address: *Contact Phone:
Medicare No: (10 digit number) Medicare Reference No: (The 1 digit number to the left of your name)
*Departure Date: Open Calendar (dd/mm/yyyy) *Return Date: Open Calendar (dd/mm/yyyy)
I will be visiting the following countries:
 # Countries (in order of visit) Duration Cities Rural More Information
More Countries:
  1. Please review all details before proceeding to next step.
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  3. To cancel and close this window, click on the Cancel button.
* Indicates required fields.